During the first 24 hours postburn, fluid replacement is the treatment priority. The assessment that would alert the nurse that the fluid protocol is ineffective is:
1. rectal temperature of 101ยบ F.
2. urine output of 20 mL/hour.
3. crackles in the lower left lobe.
4. marked edema in the burn area.
2
Decreased urinary output indicates that there is still poor perfusion to the kidney. Tempera-ture elevation and edema are to be expected. Crackles in a dormant patient are not a cause for alarm.
PTS: 1 DIF: Cognitive Level: Analysis REF: 1150
OBJ: 5 TOP: Burns: Fluid Replacement
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment
You might also like to view...
In which of the following ways does the LPN/LVN contribute to the nursing process? Select all that apply. Standard Text: Select all that apply
1. Stocking the client's room with needed supplies 2. Giving the client a bath and back rub 3. Changing the client's linen 4. Documenting the client response to Tylenol given for a fever 5. Notifying the RN of deteriorating vital signs
Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression
As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A) Urinary output increases B) Skin becomes warm and dry C) Adventitious lung sounds occur in the upper airway D) Heart and respiratory rates are elevated
Calculate the daily rate of maintenance fluids and the IV hourly flow rate for a child who weighs 25 kilograms
1. 500 mL per day; 20.8 mL per hour 2. 170 mL per day; 7 mL per hour 3. 600 mL per day; 25 mL per hour 4. 1600 mL per day; 66 mL per hour
At what point in the nurse-patient relationship should a nurse first address termination?
a. Preorientation phase b. Orientation phase c. Working phase d. Termination phase